Thursday, July 11, 2013

The return of PD: Can PD strike back?

AKI is diagnosed. You need to start dialysis... can you use PD as an option? This was historically done but trends have changed and extracorporeal blood purification( CVVHDF, HD) gets offered only. A recent article in CJASN did a systematic review on this topic.  Based on their analysis, they found 24 studies that was good to evaluate and included 1556 patients.

Brief points
1. 13/24 studies were PD only with pooled mortality was 39.3%
2. In randomized trials, no difference in mortality between PD vs HD for AKI
3. But the trials were significantly had intertrial heterogeneity.
4. Most of the complications with PD were peritonitis
5. Low resource settings and developing countries had more experience on this use than developed countries. Studies from Europe and North America were very low numbers.

Fellowship training in US might play a significant role in this trend we are seeing in US. In US, 30% of new nephrologists felt competent with acute PD compared to 90% of new nephrologists felt competent for acute HD. Few years ago, we had presented an abstract NKF 2011(page 272) on health care professional dialysis choices in case they needed dialysis.  There is scarce data on what a heathcare professional
would choose for themselves. The survey  consisted of seven questions aimed at assessing choice a health care  provider would make for themselves. We posed these questions to  physicians, nephrologists,nurses,dialysis nurses and nephrology fellows  in training. What we found was that  51.2% of health care professionals chose PD to be their choice of therapy. Among those who  chose HD 87% chose one of Home HD modality with only 13%  choosing in-center HD; far from evident in our current US statistics for  ESRD patients. 45.7% chose Nocturnal Long HD(6-8 hr,3 times/wk)
,31.5% Daily Short Home HD(2-3 hr,5-6 times/wk), 9.8% Home HD (3 hr 3times/wk).70.5 % chose a modality based on a belief of better outcomes of one over the modality.57.3% responders reported the
quality of life to be the specific outcome which was better for the  modality they opted for with 35.4% choosing the modality based on better morbidity, mortality and survival data. In center HD was the
modality most health care providers were comfortable discussing with their patients with only 18.7 % being comfortable in discussing PD.

PD needs to strike back!

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